Virtual Reality Distraction Is No Better Than Simple Distraction Techniques for Reducing Pain and Anxiety During Pediatric Orthopaedic Outpatient Procedures: A Randomized Controlled Trial.

BACKGROUND: In-office procedures can be painful and anxiety-provoking for pediatric patients. Minimizing such pain and anxiety in children improves the patient experience and promotes a rewarding and productive patient-caregiver-provider relationship, which may for some young patients be their first memorable encounter with the healthcare system. Although virtual reality (VR) techniques have proven to be helpful in minimizing pain and anxiety during procedures in pediatric intensive care settings, it remains unclear how VR affects objective and subjective measures of pain and anxiety in children undergoing in-office orthopaedic procedures such as cast removal or percutaneous pin removal after fracture healing. QUESTIONS/PURPOSES: Is a VR gaming simulation more effective than either of two forms of noninteractive visual distraction (VR goggles or tablet computer displaying a noninteractive video) for reducing (1) objective measures of pain and anxiety and (2) subjective measures of pain and anxiety in children undergoing in-office cast removal or percutaneous pin removal? METHODS: This study was a randomized controlled trial with two parallel, separately analyzed cohorts: children undergoing in-office cast removal or in-office percutaneous pin removal at a single urban tertiary institution. We approached eligible patients who were scheduled to undergo outpatient cast or percutaneous pin removal and who met prespecified inclusion criteria. We enrolled until 105 patients were available for analysis in each of the cast removal and pin removal cohorts. Of note, the study institution was in an urban epicenter of the coronavirus-19 pandemic, and clinical research was paused sporadically, which resulted in a longer-than-expected enrollment period. In the cast removal cohort, all patients were eligible for inclusion and were enrolled and randomized into one of three groups: VR gaming simulation (n = 37), VR goggles with a noninteractive video (n = 36), or a tablet computer with the same noninteractive video (n = 40). Eleven percent (4), 8% (3), and 3% (1) withdrew from each of the three intervention groups, respectively. In the pin removal cohort, all patients were eligible for inclusion and were enrolled and randomized into the same three groups (37, 44, and 41 patients, respectively). In the pin removal group, 14% (5), 18% (8), and 10% (4) withdrew from each of the three intervention groups, respectively. In all, 235 patients were enrolled in the study and 210 patients (mean ± SD age 9 ± 3 years; 48% [100] girls) were included in the final analyses. There were no clinically important differences in age, gender, preprocedure pain, or anxiety among the intervention groups. Primary outcomes included preprocedure-to-maximum heart rate increase (objective measure) and preprocedure and postprocedure pain and anxiety using a VAS (subjective measures). One-way ANOVA and Bonferroni-adjusted pairwise comparisons were used to calculate between-group differences for the primary outcomes. RESULTS: There were no intervention-level groupwise differences between VR goggles with an interactive game, VR goggles with a noninteractive video, or the tablet computer with the same video in preprocedure-to-maximum heart rate increase in the cast removal cohort (18 ± 21 bpm versus 14 ± 11 bpm versus 20 ± 16 bpm, respectively; largest mean difference -6 bpm [95% CI -16 to 3]; p = 0.36) or pin removal cohort (27 ± 20 bpm versus 23 ± 12 bpm versus 24 ± 19 bpm, respectively; largest mean difference 4 bpm [95% CI -7 to 14]; p = 0.99). Similarly, there were no intervention-level groupwise differences in preprocedure to postprocedure VAS pain in the cast removal cohort (1 ± 1 versus 1 ± 2 versus 0 ± 2, respectively; largest mean difference 0 points [95% CI 0 to 1]; p = 0.89) or pin removal cohort (0 ± 3 versus 2 ± 3 versus 0 ± 3 points, respectively; largest mean difference 1 point [95% CI 0 to 3]; p = 0.13). Finally, there were no intervention-level groupwise differences between the same intervention groups in preprocedure to postprocedure VAS anxiety in the cast removal cohort (-2 ± 2 versus -1 ± 2 versus -1 ± 2 points, respectively; largest mean difference -1 point [95% CI -2 to 1]; p = 0.63) or pin removal cohort (-3 ± 3 versus -4 ± 4 versus -3 ± 3 points, respectively; largest mean difference -1 point [95% CI -2 to 1]; p = 0.99). CONCLUSION: During in-office cast and pin removal in pediatric patients, simple distraction techniques such as tablet video viewing are as effective as higher-fidelity VR headset video and interactive games in minimizing objective measures of procedural pain and subjective measures of pain and anxiety. Because of these findings and because of the associated costs, implementation logistics, and variable tolerance by young patients, widespread use of VR distraction techniques in the pediatric orthopaedic outpatient setting is unnecessary. LEVEL OF EVIDENCE: Level I, therapeutic study.

The findings of preoperative cardiac screening studies in adolescent idiopathic scoliosis.

INTRODUCTION: We sought to evaluate findings of screening cardiac studies in adolescent idiopathic scoliosis (AIS) patients by reviewing the echocardiograms and electrocardiograms (EKGs) performed at their preoperative evaluation for spinal fusion. METHODS: Retrospective chart review of all surgical AIS patients from 2000 to 2007 was completed (n=212). Patients with neuromuscular scoliosis, known connective tissue disease, or known/suspected cardiac disease were excluded. In presurgical screening, 12 lead EKG, 2dimensional-Doppler, and M-mode echocardiograms were analyzed. RESULTS: A total of 154 (73%) female and 58 (27%) male patients (aged 12 to 18 y, avg: 14.8 y) were analyzed. EKG findings, 180/212 (85%), were within normal limits. Twenty-eight of 212 (13%) patients were found to have normal variant readings. Four of 212 (2%) patients met criteria for left ventricular hypertrophy on EKG, but were subsequently found to have normal echocardiograms. Significant echocardiogram findings revealed 2 (0.94%) subjects with atrial septal defects (ASDs) (that delayed surgery) and 7 (3.3%) subjects with aortic root/valve abnormalities. CONCLUSIONS: In our cohort of preoperative AIS patients, cardiac abnormalities ranged from mild to severe, and in 2 cases, affected the surgical timing. Novel findings of aortic abnormalities were identified in 3.3% of patients. In a study which examined the prevalence of heart disease in randomly selected healthy adolescents with previously unknown cardiac disease (Steinberger), there was a rate of 3.6% (13/357) of cardiac anomalies. Of note, only 0.6% had aortic root/valve findings. The results of our retrospective review indicate that EKG does not provide significant information compared with echocardiogram as part of the preoperative evaluation of asymptomatic and otherwise healthy patients with AIS who are undergoing spinal deformity surgery. However, use of the echocardiogram may be appropriate for the diagnosis of previously unknown cardiac abnormalities in this population, as aortic root/valve abnormalities seem to be unique findings in these patients. LEVEL OF EVIDENCE: Level IV, Retrospective, descriptive case series.

The relationship between developmental dysplasia of the hip and congenital muscular torticollis.

Multiple studies report a correlation between congenital muscular torticollis (CMT) and developmental dysplasia of the hip (DDH) at a rate between 2% and 29%. Most of these studies were completed before the routine use of hip ultrasound. This study assesses the incidence of DDH in a referral population with CMT and the incidence of CMT in a referral population with DDH. We retrospectively reviewed 186 patients referred with a primary diagnosis of DDH and 109 patients referred with a primary diagnosis of CMT between 1995 and 2004. All patients were screened for DDH with ultrasound if they were younger than 4 months and plain radiographs in older children. Among the patients with a primary diagnosis of DDH, 5.9% were subsequently diagnosed with CMT. However, infants who were less than 1 month old when diagnosed with DDH had a 9% risk of subsequent development of CMT. Among the patients primarily diagnosed with CMT, 3.7% were subsequently diagnosed with DDH. Among the patients with DDH, there was a 7.9% coexistence of CMT, regardless of which was diagnosed first, and among the patients with CMT, there was a 12.5% coexistence of DDH. Boys with DDH were 4.97 times more likely than girls to have both DDH and CMT regardless of which diagnosis preceded the other. Our results confirm that patients with CMT should be screened for DDH, and infants, especially boys, treated for DDH should be followed for the development of CMT.